Notice
of Privacy Practices

 

Talbot
Health Services is committed to providing excellent outpatient behavioral
healthcare services. An important part of providing these services is
protecting your health information according to applicable laws. This is a
Notice of Privacy Practices describes your rights under Federal law. We are
required by law to maintain the privacy of protected health information, to
provide individuals with notice of our legal duties and privacy practices with
respect to protected health information, and to notify affected individuals
following a breach of unsecured protected health information. This notice
describes how we may use and disclose your healthcare information. It also
describes your rights and our legal obligations with respect to your healthcare
information.

 

Protected
Health Information (PHI) includes information about you to include demographic
information, which may identify you and that relates to your past, present or
future physical or mental health condition, the provision of healthcare
services, or the past, present, or future payment for the provision of
healthcare services to you.

 

Talbot
Health Services is required by law to maintain the privacy of your PHI, provide
you with notice our legal duties and privacy practices with respect to you PHI.
Talbot Health Services is required to notify you following any breach of
unsecured PHI related to you. We are required to modify this Notice of Privacy
Practices will remain in effect until it is revised. Talbot Health Services is
required to modify this Notice of Privacy Practices when there are material
changes to your rights, our duties, or other practices contained herein.

 

Talbot
Health Services reserves the right to change our privacy policy and practices
and the terms of this Notice of Privacy Practices, consistent with applicable
law and our current business processes, at any time. Any new Privacy Practices
will be effective for all PHI that we maintain at that time. Notification of
revisions of this Notice of Privacy practices will be provided as follows upon
request, electronically via our website or via other electronic means, or as
posted in our facilities.

 

In
addition to the above, we have a duty to respond to your requests in a timely
and appropriate manner. We value your rights to privacy and are committed to
maintaining reasonable and appropriate safeguards for your PHI.

 

Substance
use disorder client records maintained by Talbot Health Services are also
protected by Federal law and regulations. These laws and regulations provide
that:

 

Talbot
Health Services may not disclose to a person outside the treatment program that
you are present in the facility, that you are a client in our program or any
other information identifying you as having or having had a substance use
disorder.

Talbot
Health Services, except under specific circumstances described in the federal
regulations, we will not disclose any of your substance use disorder client
information to any person outside of Talbot Health Services program unless you
consent in writing.

Information
related to our commission of a crime on the premises of the treatment facility
or against personnel of the treatment facility is not protected and any reports
of suspected child abuse and neglect under state law to appropriate state or
local authorities in not protected (See 42 U.S. C. 290dd-3 and 42 U.S. C.
290ee-3 for Federal laws and 42 CFR part 2 for Federal regulations).

 

Violation
of the Federal law and regulations by the treatment facility is a crime. Suspected
violations may be reported to United States Attorney for the judicial district
in which the violation occurs as well as to the Substance Abuse and Mental
Health Services (SAMHSA) office responsible for oversight of the treatment
center.

 

Permitted Uses and Disclosures

 

Uses
and Disclosures of your PHI may be permitted, required, or authorized. The
following categories describe various ways that Talbot Health Services use and
disclose PHI.

 

Among
Talbot Health Services staff: We may use or disclose information between or
among personnel having a need for the information in connection with their
duties that arise out of provision of diagnosis, treatment, or referral for
treatment of alcohol or drug use, provided such communication is 1) within the
treatment center 2) between the treatment center and Talbot Health Services. For
example, Talbot Health Services staff, which includes medical providers,
nurses, clinicians, will use your PHI to provide your treatment care. Your PHI
may be used in connection with billing statements we send you and in connection
with tracking charges and credits to your account. Your PHI will be used to
check for eligibility for insurance coverage and prepare claims for your
insurance company where appropriate. Talbot Health Services may use and disclose
your PHI to conduct our healthcare business and to perform functions associated
with our business activities, including accreditation and licensing.

Secretary of Health and Human Services:  Talbot Health
Services is required to disclose PHI to the Secretary of the U.S. Department of
Health and Human Services when the Secretary is investigating or determining
our compliance with the HIPAA Privacy Rules.

Business Associates: 
Talbot
Health Services may disclose your PHI to Business Associates that are
contracted by use to perform services on our behalf which may involve receipt,
use or disclosure of your PHI.

All of our Business Associate must
agree to: 

1)     
Protect
the privacy of your PHI.

2)     
use
and disclose the information only for the purposes for which the Business
Associate was engaged;

3)     
be
bound by 42 CFR Part 2 and

4)     
if
necessary, resist in judicial proceedings any efforts to obtain access to client
records except as permitted by law.

Crimes on premises: 
Talbot
Health Services may disclose to law enforcement officer’s information that are related
directly to the commission of a crime on the premises or against our personnel
or to a threat to commit such a crime.

Reports of Suspected Child Abuse and Neglect: 
Talbot
Health Services may disclose information required to report under state law
incident of suspected child abuse and neglect to the appropriate state or local
authorities. However, we may not disclose the original client records,
including for civil or cranial proceedings which may arise out of the report of
suspected child abuse and neglect, without consent.

Treatment is the provision, coordination, or management of
health care and related services for an individual by one or more health care
providers, including consultation between providers regarding a client and
referral of a client by one provider to another.

1. Payment encompasses activities of a health plan to
   obtain premiums, determine or fulfill responsibilities for coverage and provision
   of benefits, and furnish or obtain reimbursement for health care delivered
   to an individual and activities of a health care provider to obtain
   payment or be reimbursed for the provision of health care to an
   individual.
2. Health care operations are any of the
   following activities: (a) quality assessment and improvement activities,
   including case management and care coordination; (b) competency assurance
   activities, including provider or health plan performance evaluation,
   credentialing, and accreditation, (c) conducting or arranging for medical
   reviews, audits, or legal services, including fraud and abuse detection
   and compliance programs (d) specified insurance functions, such as
   underwriting, risk rating, and reinsuring risk, (e) business planning,
   development, management, and administration, and (f) business management
   and general administrative activities of the entity, including but not
   limited to: de-identifying protected health information, creating a
   limited data set, and certain fundraising for the benefit of the covered
   entity.

Most uses
and disclosures of psychotherapy notes for treatment, payment, and health care
operations purposes require an authorization as described below. Obtaining
“consent” (written permission from individuals to use and disclose their
protected health information for treatment, payment, and health care
operations) is optional under the Privacy Rule for all covered entities. The
content of a consent form, and the process for obtaining consent, are at the
discretion of the covered entity electing to seek consent. 

Uses and
Disclosures with Opportunity to Agree or Object

Informal
permission may be obtained by asking the individual outright, or by
circumstances that clearly give the individual the opportunity to agree,
acquiesce, or object. Where the individual is incapacitated, in an emergency
situation, or not available, covered entities generally may make such uses and
disclosures, if in the exercise of their professional judgment, the use or
disclosure is determined to be in the best interests of the individual.

1. Facility Directories It is a common practice
   in many health care facilities, such as hospitals, to maintain a directory
   of client contact information. A covered health care provider may rely on
   an individual’s informal permission to list in its facility directory the
   individual’s name, general condition, religious affiliation, and location
   in the provider’s facility. The provider may then disclose the
   individual’s condition and location in the facility to anyone asking for
   the individual by name, and also may disclose religious affiliation to
   clergy. Members of the clergy are not required to ask for the individual
   by name when inquiring about client religious affiliation. 
2. For Notification and Other
   Purposes: A
   covered entity also may rely on an individual’s informal permission to
   disclose to the individual’s family, relatives, or friends, or to other
   persons whom the individual identifies, protected health information
   directly relevant to that person’s involvement in the individual’s care or
   payment for care. This provision, for example, allows a pharmacist to
   dispense filled prescriptions to a person acting on behalf of the client.
   Similarly, a covered entity may rely on an individual’s informal
   permission to use or disclose protected health information for the purpose
   of notifying (including identifying or locating) family members, personal
   representatives, or others responsible for the individual’s care of the
   individual’s location, general condition, or death. In addition, protected
   health information may be disclosed for notification purposes to public or
   private entities authorized by law or charter to assist in disaster relief
   efforts.

Incidental Use
and Disclosure

 The
Privacy Rule does not require that every risk of an incidental use or
disclosure of protected health information be eliminated. A use or disclosure
of this information that occurs as a result of, or as “incident to,” an
otherwise permitted use or disclosure is permitted as long as the covered
entity has adopted reasonable safeguards as required by the Privacy Rule, and
the information being shared was limited to the “minimum necessary,” as
required by the Privacy Rule. See “Incidental Uses and Disclosures.” 

(5) Public
Interest and Benefit Activities

 The
Privacy Rule permits use and disclosure of protected health information,
without an individual’s authorization or permission, for twelve national
priority purposes. These disclosures are permitted, although not required, by
the Rule in recognition of the important uses made of health information
outside of the health care context. Specific conditions or limitations apply to
each public interest purpose, striking the balance between the individual
privacy interest and the public interest need for this information.

1. Required by Law Covered entities may
   use and disclose protected health information without individual
   authorization as required by law (including by statute,
   regulation, or court orders). 
2. Public Health Activities Covered entities may
   disclose protected health information to: (1) public health authorities
   authorized by law to collect or receive such information for preventing or
   controlling disease, injury, or disability and to public health or other
   government authorities authorized to receive reports of child abuse and
   neglect; (2) entities subject to FDA regulation regarding FDA regulated
   products or activities for purposes such as adverse event reporting,
   tracking of products, product recalls, and post-marketing surveillance;
   (3) individuals who may have contracted or been exposed to a communicable
   disease when notification is authorized by law; and (4) employers,
   regarding employees, when requested by employers, for information
   concerning a work-related illness or injury or workplace related medical
   surveillance, because such information is needed by the employer to comply
   with the Occupational Safety and Health Administration (OHSA), the Mine
   Safety and Health Administration (MHSA), or similar state law. See OCR
   “Public Health” Guidance, CDC Public Health and HIPAA Guidance. 
3. Victims of Abuse, Neglect or
   Domestic Violence In
   certain circumstances, covered entities may disclose protected health
   information to appropriate government authorities regarding victims of
   abuse, neglect, or domestic violence. 
4. Health Oversight Activities Covered entities may
   disclose protected health information to health oversight agencies (as
   defined in the Rule) for purposes of legally authorized health oversight
   activities, such as audits and investigations necessary for oversight of
   the health care system and government benefit programs. 
5. Judicial and Administrative
   Proceedings Covered
   entities may disclose protected health information in a judicial or
   administrative proceeding if the request for the information is through an
   order from a court or administrative tribunal. Such information may also
   be disclosed in response to a subpoena or other lawful process if certain
   assurances regarding notice to the individual or a protective order are
   provided. 
6. Law
   Enforcement Purposes Covered entities may disclose protected
   health information to law enforcement officials for law enforcement
   purposes under the following six circumstances, and subject to specified
   conditions: (1) as required by law (including court orders, court-ordered
   warrants, subpoenas) and administrative requests; (2) to identify or
   locate a suspect, fugitive, material witness, or missing person; (3) in
   response to a law enforcement official’s request for information about a
   victim or suspected victim of a crime; (4) to alert law enforcement of a
   person’s death, if the covered entity suspects that criminal activity
   caused the death; (5) when a covered entity believes that protected health
   information is evidence of a crime that occurred on its premises; and (6)
   by a covered health care provider in a medical emergency not occurring on
   its premises, when necessary to inform law enforcement about the
   commission and nature of a crime, the location of the crime or crime
   victims, and the perpetrator of the crime. 

   Decedents Covered entities may disclose protected health
   information to funeral directors as needed, and to coroners or medical
   examiners to identify a deceased person, determine the cause of death, and
   perform other functions authorized by law. 

7. Cadaveric Organ, Eye, or
   Tissue Donation Covered
   entities may use or disclose protected health information to facilitate
   the donation and transplantation of cadaveric organs, eyes, and
   tissue. 
8. Research “Research” is any
   systematic investigation designed to develop or contribute to
   generalizable knowledge. The Privacy Rule permits a covered entity to use
   and disclose protected health information for research purposes, without
   an individual’s authorization, provided the covered entity obtains either:
   (1) documentation that an alteration or waiver of individuals’
   authorization for the use or disclosure of protected health information
   about them for research purposes has been approved by an Institutional Review
   Board or Privacy Board; (2) representations from the researcher that the
   use or disclosure of the protected health information is solely to prepare
   a research protocol or for similar purpose preparatory to research, that
   the researcher will not remove any protected health information from the
   covered entity, and that protected health information for which access is
   sought is necessary for the research; or (3) representations from the
   researcher that the use or disclosure sought is solely for research on the
   protected health information of decedents, that the protected health
   information sought is necessary for the research, and, at the request of
   the covered entity, documentation of the death of the individuals about
   whom information is sought. A covered entity also may use or disclose,
   without an individuals’ authorization, a limited data set of protected
   health information for research purposes (see discussion below). See OCR
   “Research” Guidance; NIH Protecting PHI in Research. 
9. Serious Threat to Health or
   Safety Covered
   entities may disclose protected health information that they believe is
   necessary to prevent or lessen a serious and imminent threat to a person
   or the public, when such disclosure is made to someone they believe can
   prevent or lessen the threat (including the target of the threat). Covered
   entities may also disclose to law enforcement if the information is needed
   to identify or apprehend an escapee or violent criminal.
10. Essential Government
    Functions An
    authorization is not required to use or disclose protected health
    information for certain essential government functions. Such functions
    include: assuring proper execution of a military mission, conducting
    intelligence and national security activities that are authorized by law,
    providing protective services to the President, making medical suitability
    determinations for U.S. State Department employees, protecting the health
    and safety of inmates or employees in a correctional institution, and
    determining eligibility for or conducting enrollment in certain government
    benefit programs. 
11. Workers’ Compensation Covered entities may
    disclose protected health information as authorized by, and to comply
    with, workers’ compensation laws and other similar programs providing
    benefits for work-related injuries or illnesses. See OCR “Workers’
    Compensation” Guidance.

Limited Data
Set

A limited
data set is protected health information from which certain specified direct
identifiers of individuals and their relatives, household members, and
employers have been removed. A limited data set may be used and disclosed for
research, health care operations, and public health purposes, provided the
recipient enters into a data use agreement promising specified safeguards for
the protected health information within the limited data set. 

 

 

The information will be viewed by staff and any legally
licensed Medication Assisted Treatment facility in the United States
when you present and request enrollment and/or emergency medication services.
In addition, the above-described information could be released to any duly
appointed State Opioid Treatment Authority and their staff for the purposes of
monitoring dual enrollment verifications.